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Bleeding and Anticoagulation
UFH is still the most cost
effective
Christian Spaulding, MD, FESC
Cardiology Department
Hôpital Européen Georges Pompidou, Paris Descartes
University
INSERM U 970, PARCC
Paris, France
Conflicts of interest
• Advisory board: Medtronic
• Speaker’s bureau: Lilly, Iroko, Servier, Astra Zeneca,
Cordis
• Research grants from the French government on
cardiac arrest
What are we trying to achieve?
• We want to be cost effective
• We don’t want the radial artery to occlude after a
coronary angiogram: you may need it again for PCI
• For PCI we want to avoid per and post-procedural
complications such as stent thrombosis, and
bleeding complications
Cost effectiveness
• Prices in an University Hospital in Paris, France,
(patient 70 kg):
– UFH 5000 IU: 0,3 euros
– LMWH 35 mg: 0,9 euros
– Bivalirudin 250 mg: 408 euros

Christian and Gilles ?

Sunil and co?
What are we trying to achieve?
• We want to be cost effective
• We don’t want the radial artery to occlude after a
coronary angiogram: you may need it again for PCI
• For PCI we want to avoid per and post-procedural
complications such as stent thrombosis, and
bleeding complications
Heparin prevents radial artery occlusion, but:
• What is the right dose?
– UFH 50 IU/Kg or 5000 IU seem more effective

1

• Intra-arterial or systemic?
– No difference 2
• Heparin is not the only factor for radial artery occlusion 3:
– Radial artery size
– Female gender, lower body weight
– Sheath size
– Numerous procedures through the same artery
– Systolic blood pressure at hemostasis
– Hemostasis technique
Bernat I et al, Am J Cardiol 2011;107:1698–1701
2
Pancholy SB et al Am J Cardiol 2009;104:1083–1085
3
Hamon M et al EuroIntervention 2013;8:1242-1251
1
What are we trying to achieve?
• We want to be cost effective
• We don’t want the radial artery to occlude after a
coronary angiogram
• For PCI we want to avoid per and post-procedural
complications such as stent thrombosis, and
bleeding complications
Achieving a balance in prevention of
ischemia and bleeding complications
Planned PCI: STEEPLE

« The trial was not large enough to provide a definitive comparison
of efficacy in the prevention of ischemic events »

Montalescot G et al, N Engl J Med 2006;355:1006-17
ATOLL Trial design
Randomization as early as possible (MICU +++)
Real life population (shock, cardiac arrest included) 
No anticoagulation and no lytic before Rx
Similar antiplatelet therapy in both groups

STEMI  Primary PCI
ENOXAPARIN IV
0.5 mg/kg

UFH IV
IVRS

with or without GPIIbIIIa

50-70 IU with GP IIbIIIa
70-100IU without GP IIbIIIa
(Dose ACT-adjusted)

Primary PCI
UFH IV or SC

ENOXAPARIN SC

30-day results
Montalescot G et al, Lancet. 2011;378:693-703 
Bivalirudin reduced both ischemic and bleeding events in femoral-treated patients,
no benefit in the radial-treated patients

MacHaalany J et al, Am J Cardiol 2012;110:1742–1748
What are we trying to achieve?
• We want to be cost effective
• We don’t want the radial artery to occlude after a
coronary angiogram: you may need it again for PCI
• For PCI we want to avoid per and post-procedural
complications such as stent thrombosis, and
bleeding complications
How can we achieve these goals
• Limited data on the use of anticoagulants in radial
procedures
• Coronary angiograms
– 5000 IU UFH prevents radial occlusion
• Planned PCI, STEMI or NSTEMI: what is the « firstline » anticoagulant?
– UFH or LMWH ++
– Bivalirudin reduces bleeding complications
however the benefit seems mitigated by the use
of radial approach, there is no dedicated trial on
bivalirudin + radial approach and cost is a serious
limitation

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Spaulding C - AIMRADIAL 2013 - Heparin and radial

  • 1. Bleeding and Anticoagulation UFH is still the most cost effective Christian Spaulding, MD, FESC Cardiology Department Hôpital Européen Georges Pompidou, Paris Descartes University INSERM U 970, PARCC Paris, France
  • 2. Conflicts of interest • Advisory board: Medtronic • Speaker’s bureau: Lilly, Iroko, Servier, Astra Zeneca, Cordis • Research grants from the French government on cardiac arrest
  • 3. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  • 4. Cost effectiveness • Prices in an University Hospital in Paris, France, (patient 70 kg): – UFH 5000 IU: 0,3 euros – LMWH 35 mg: 0,9 euros – Bivalirudin 250 mg: 408 euros Christian and Gilles ? Sunil and co?
  • 5. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  • 6.
  • 7. Heparin prevents radial artery occlusion, but: • What is the right dose? – UFH 50 IU/Kg or 5000 IU seem more effective 1 • Intra-arterial or systemic? – No difference 2 • Heparin is not the only factor for radial artery occlusion 3: – Radial artery size – Female gender, lower body weight – Sheath size – Numerous procedures through the same artery – Systolic blood pressure at hemostasis – Hemostasis technique Bernat I et al, Am J Cardiol 2011;107:1698–1701 2 Pancholy SB et al Am J Cardiol 2009;104:1083–1085 3 Hamon M et al EuroIntervention 2013;8:1242-1251 1
  • 8. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  • 9. Achieving a balance in prevention of ischemia and bleeding complications
  • 10.
  • 12. ATOLL Trial design Randomization as early as possible (MICU +++) Real life population (shock, cardiac arrest included)  No anticoagulation and no lytic before Rx Similar antiplatelet therapy in both groups STEMI  Primary PCI ENOXAPARIN IV 0.5 mg/kg UFH IV IVRS with or without GPIIbIIIa 50-70 IU with GP IIbIIIa 70-100IU without GP IIbIIIa (Dose ACT-adjusted) Primary PCI UFH IV or SC ENOXAPARIN SC 30-day results Montalescot G et al, Lancet. 2011;378:693-703 
  • 13.
  • 14.
  • 15.
  • 16. Bivalirudin reduced both ischemic and bleeding events in femoral-treated patients, no benefit in the radial-treated patients MacHaalany J et al, Am J Cardiol 2012;110:1742–1748
  • 17. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  • 18. How can we achieve these goals • Limited data on the use of anticoagulants in radial procedures • Coronary angiograms – 5000 IU UFH prevents radial occlusion • Planned PCI, STEMI or NSTEMI: what is the « firstline » anticoagulant? – UFH or LMWH ++ – Bivalirudin reduces bleeding complications however the benefit seems mitigated by the use of radial approach, there is no dedicated trial on bivalirudin + radial approach and cost is a serious limitation